ABSTRACT Alcohol use among women of childbearing age is a leading, preventable cause of birth defects and developmental disabilities in the United States. Although most women reduce their alcohol use upon pregnancy recognition, some women report drinking during pregnancy and others may continue to drink prior to realizing they are pregnant. These findings emphasize the need for effective prevention strategies for both pregnant and nonpregnant women who might be at risk for an alcohol-exposed pregnancy (AEP). This report reviews evidence supporting alcohol screening and brief intervention as an effective approach to reducing problem drinking and AEPs that can lead to fetal alcohol spectrum disorders. In addition, this article highlights a recent report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect that describes effective interventions to reduce alcohol use and AEPs, and outlines recommendations on promoting and improving these strategies. Utilizing evidence-based alcohol screening tools and brief counseling for women at risk for an AEP and other effective population-based strategies can help achieve future alcohol-free pregnancies.

[Show abstract][Hide abstract]ABSTRACT:
Non-pregnant women can avoid alcohol-exposed pregnancies (AEPs) by modifying drinking and/or contraceptive practices. The purpose of this study was to estimate the number and characteristics of women in the United States who are at risk of AEPs. We analyzed data from in-person interviews obtained from a national probability sample (i.e., the National Survey of Family Growth) of reproductive-aged women conducted from January 2002 to March 2003. To be at risk of AEP, a woman had to have met the following criteria in the last month: (1) was drinking; (2) had vaginal intercourse with a man; and (3) did not use contraception. During a 1-month period, nearly 2 million U.S. women were at risk of an AEP (95 % confidence interval 1,760,079-2,288,104), including more than 600,000 who were binge drinking. Thus, 3.4 %, or 1 in 30, of all non-pregnant women were at risk of an AEP. Most demographic and behavioral characteristics were not clearly associated with AEP risk. However, pregnancy intention was strongly associated with AEP risk (prevalence ratio = 12.0, P < 0.001) because women often continued to drink even after they stopped using contraception. Nearly 2 million U.S. women are at AEP risk and therefore at risk of having children born with fetal alcohol spectrum disorders. For pregnant women and women intending a pregnancy, there is an urgent need for wider implementation of prevention programs and policy approaches that can reduce the risk for this serious public health problem.

[Show abstract][Hide abstract]ABSTRACT:
Stem cells, especially human embryonic stem cells (hESCs), are useful models to study molecular mechanisms of human disorders that originate during gestation. Alcohol (ethanol, EtOH) consumption during pregnancy causes a variety of prenatal and postnatal disorders collectively referred to as fetal alcohol spectrum disorders (FASDs). To better understand the molecular events leading to FASDs, we performed a genome-wide analysis of EtOH's effects on the maintenance and differentiation of hESCs in culture. Gene Co-expression Network Analysis showed significant alterations in gene profiles of EtOH-treated differentiated or undifferentiated hESCs, particularly those associated with molecular pathways for metabolic processes, oxidative stress, and neuronal properties of stem cells. A genome-wide DNA methylome analysis revealed widespread EtOH-induced alterations with significant hypermethylation of many regions of chromosomes. Undifferentiated hESCs were more vulnerable to EtOH's effect than their differentiated counterparts, with methylation on the promoter regions of chromosomes 2, 16 and 18 in undifferentiated hESCs most affected by EtOH exposure. Combined transcriptomic and DNA methylomic analysis produced a list of differentiation-related genes dysregulated by EtOH-induced DNA methylation changes, which likely play a role in EtOH-induced decreases in hESC pluripotency. DNA sequence motif analysis of genes epigenetically altered by EtOH identified major motifs representing potential binding sites for transcription factors. These findings should help in deciphering the precise mechanisms of alcohol-induced teratogenesis.

[Show abstract][Hide abstract]ABSTRACT:
The behavioral consequences of fetal alcohol spectrum disorders (FASD) are serious and persist throughout life. The causative mechanisms underlying FASD are poorly understood. However, much has been learned about FASD from human structural and functional studies as well as from animal models, which have provided a greater understanding of the mechanisms underlying FASD. Using animal models of FASD, it has been recently discovered that ethanol induces neuroimmune activation in the developing brain. The resulting microglial activation, production of proinflammatory molecules, and alteration in expression of developmental genes are postulated to alter neuron survival and function and lead to long-term neuropathological and cognitive defects. It has also been discovered that microglial loss occurs, reducing microglia's ability to protect neurons and contribute to neuronal development. This is important, because emerging evidence demonstrates that microglial depletion during brain development leads to long-term neuropathological and cognitive defects. Interestingly, the behavioral consequences of microglial depletion and neuroimmune activation in the fetal brain are particularly relevant to FASD. This chapter reviews the neuropathological and behavioral abnormalities of FASD and delineates correlates in animal models. This serves as a foundation to discuss the role of the neuroimmune system in normal brain development, the consequences of microglial depletion and neuroinflammation, the evidence of ethanol induction of neuroinflammatory processes in animal models of FASD, and the development of anti-inflammatory therapies as a new strategy for prevention or treatment of FASD. Together, this knowledge provides a framework for discussion and further investigation of the role of neuroimmune processes in FASD.

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PREVENTION OF FETAL ALCOHOL SPECTRUMDISORDERSR. Louise Floyd,1* Mary Kate Weber,1Clark Denny,1and Mary J. O’Connor21Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities,Prevention Research Branch, Fetal Alcohol Syndrome Prevention Team, Atlanta, Georgia2Department of Psychiatry and Biobehavioral Sciences, Semel Institute of Neuroscience and Human Behavior,David Geffen School of Medicine at UCLA, Los Angeles, CaliforniaAlcohol use among women of childbearing age is a leading, pre-ventable cause of birth defects and developmental disabilities in theUnited States. Although most women reduce their alcohol use uponpregnancy recognition, some women report drinking during pregnancyand others may continue to drink prior to realizing they are pregnant.These findings emphasize the need for effective prevention strategies forboth pregnant and nonpregnant women who might be at risk for analcohol-exposed pregnancy (AEP). This report reviews evidence support-ing alcohol screening and brief intervention as an effective approach toreducing problem drinking and AEPs that can lead to fetal alcohol spec-trum disorders. In addition, this article highlights a recent report of theNational Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effectthat describes effective interventions to reduce alcohol use and AEPs,and outlines recommendations on promoting and improving thesestrategies.Utilizingevidence-basedbrief counseling for women at risk for an AEP and other effectivepopulation-based strategies can help achieve future alcohol-free preg-nancies.Dev Disabil Res Rev 2009;15:193–199.alcohol screeningtoolsand'2009 Wiley-Liss, Inc.Key Words: pregnancy and alcohol; fetal alcohol syndrome; fetal alcoholspectrum disorders; alcohol use screening; brief intervention; alcohol-exposed pregnanciesAknown. Alcohol use among women of childbearing age(18–44 years) constitutes a leading, preventable cause of birthdefects and developmental disabilities in the United States[American Academy of Pediatrics, 2000]. Alcohol is a terato-gen [Michaelis and Michaelis, 1994] that can affect the devel-opment of multiple organ systems, including the central nerv-ous system, during early and later fetal development [Coles,1994; Streissguth and O’Malley, 2000]. Among nonpregnantwomen, population-based data from the Behavioral Risk Fac-tor Surveillance System (BRFSS) for years 1991–2005 findsthat ?52% report consuming any alcohol in the past monthand ?12% report binge drinking (five or more drinks on oneoccasion) (Fig. 1). Pregnancy recognition does not occur inmany women until 4- to 6-weeks gestation [Floyd et al.,1999], and thus many women may drink prior to realizinglthough the causes of many debilitating developmentaldisabilities are unknown, the etiology of fetal alcoholspectrum disorders (FASDs) [Warren et al., 2004] isthey are pregnant. Upon recognition of pregnancy, mostwomen spontaneously reduce their alcohol use [Ebrahimet al., 1999; Floyd et al., 1999]. A recent report of alcohol userates among women of childbearing age who are pregnantshowed that use of any alcohol remains stable at ?12% andbinge drinking is between 2 and 3% during pregnancy (Fig.1). Thus, alcohol use during pregnancy continues to be animportant public health concern.The timing of exposure and the amount of exposure arethe primary determinants of fetal morbidity and mortality[Michaelis and Michaelis, 1994]. A strong predictor of alcoholuse during pregnancy is alcohol use levels prior to pregnancy[Day et al., 1993; Floyd et al., 1999]. Fetal alcohol exposureprior to and after pregnancy recognition and their effect onpregnancy outcomes are important public health concerns.Rates of alcohol use for both pregnant and nonpregnantwomen of childbearing age have changed very little for over adecade [Denny et al., 2009], stressing the importance ofimplementing effective strategies to prevent prenatal alcoholexposure. This report will describe evidence-based strategiesfor reducing alcohol-exposed pregnancies (AEPs) that lead tofetal alcohol syndrome (FAS) and other prenatal alcohol-related conditions in children.SCREENING FOR ALCOHOL MISUSE IN WOMENOF CHILDBEARING AGEAlthough early studies of effective screening tools foridentifying individuals at risk for poor health outcomes relatedto alcohol consumption included both males and females,overall they tended to include predominantly more males.One systematic review focusing on screening for alcohol prob-The findings and conclusions in this report are those of the authors and do not nec-essarily represent the official position of the Centers for Disease Control andPrevention.*Correspondence to: R. Louise Floyd, Fetal Alcohol Syndrome Prevention Team,NCBDDD, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta,GA 30333. E-mail: rlf3@cdc.govReceived 25 June 2009; Accepted 14 July 2009Published online in Wiley InterScience (www.interscience.wiley.com).DOI: 10.1002/ddrr.75DEVELOPMENTAL DISABILITIESRESEARCH REVIEWS 15: 193–199 (2009)' 2009 Wiley-Liss, Inc.

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lems in primary care settings looked atstudies conducted from 1966 through1998 [Fiellin et al., 2000]. The authorsidentified 38 articles meeting inclusioncriteria which included those that werewritten in English, published in peerreview journals during the targeted timeperiod, compared the performance ofthe screening tools to a standard clinicalcriterion, and reported the performancecharacteristics of the tools such as sensi-tivity and specificity.The majority of the studies (27)focused on alcohol abuse or dependenceand the remainder (11) focused on at-risk, heavy, or harmful drinking. Avarietyofscreeninginvestigated,but theshowedtheAlcoholIdentification Test (AUDIT) [Saunderset al., 1993] performed best in identify-ing individuals with at-risk, hazardous,or harmful drinking and the CAGE[Ewing, 1984] performed best in identi-fying individuals with alcohol abuse anddependence. The AUDIT is a 10-itemscreening tool that asks questions aboutthe quantity, frequency, and maximumlevel of 5 or more drinks on one occa-sion; personal and social consequencesexperienced (problems at work or withmethodsoverallUsewereresultsDisordersthe family), and dependence symptoms(loss of control and loss of memoryabout events that occurred while drink-ing) [Saunders et al., 1993]. The CAGE[Ewing, 1984] is a four-item screenerthat includes questions on feeling theneed toCutdown;criticisms about drinking; Guilty aboutdrinking; and need for an Eye-openerfirst thing in the morning. Althoughciting a number of limitations amongthe studies reviewed, the authors con-cluded that formal screening instru-ments performed better than clinicalmeasures in identifying individuals withalcohol use problems in primary caresettings.In recognition that many standar-dized alcoholscreeningvalidated in predominantly male popu-lations,studies focusingscreening in women began to appear inthe scientific literature, including thedevelopment ofscreeningselected populations such as pregnantwomen. The first alcohol screening toolfor pregnant women was the T-ACE[Sokoletal., 1989].inquires about Tolerance (‘‘How manydrinks does it take to make you feelhigh?’’); being Annoyed by criticismsAnnoyedbytestswereonalcoholtools forTheT-ACEfrom others about one’s drinking; hav-ing felt the need to Cut down ondrinking; and the need for an Eye-openerin the morning. A secondscreening tool developed for use inpregnant women, the TWEAK [Rus-sell, 1994], is similar to the T-ACE andincludes Tolerance (‘‘How many drinkscan you hold?’’ or ‘‘How many drinksdoes it take before you begin to feel thefirst effects of alcohol?’’), Worry byfamilymembersoverbehavior exhibited, Eye-opener, Amne-sia, and need to Kut down. One reviewof alcoholusescreeningwomen in the late nineties concludedthat the CAGE, commonly used inscreening for heavy drinking in males,was less accurate in identifying problemdrinking in female populations as com-pared to the TWEAK and the AUDIT[Bradley et al., 1998]. More recently,the AUDIT-C, which includes the firstthree items of the full AUDIT thatqueries quantity, frequency, and maxi-mum level of 5 or more drinks on anyone occasion, has been found to beeffective in screening for alcohol misusein women when using a cut point scoreof 3 or more [Dawson et al., 2005;Bradley et al., 2007].thedrinkingtools forEFFICACY OF BRIEFINTERVENTIONS FORREDUCING PROBLEMDRINKING IN WOMENThe 1990s were characterized bymounting evidence supporting the useof advice and brief interventions forproblem drinkers in primary care set-tings. Some brief interventions employthe use of motivational counseling andhave been delivered by providers whoare not specialists in the treatment ofalcohol abuse or dependence. The maincomponentsoftheseinvolvefeedbackresponsibilityforadvice to change, strategies to helpindividuals reduce or stop drinking, anempathetic counseling style, and self-efficacy or optimismchange on the part of the individual.Brief intervention also involves estab-lishing a drinking goal and follow up ofprogress with ongoing support.One early review [Bien et al.,1993] reported on 32 studies of briefinterventions targeting problem drink-ingbehaviorsconductednations. Among the 6,000 subjects en-rolled in these studies, the majoritywere males (75%). Although a numberof the studies found significant effectsforbrief interventions over controlinterventionspersonalpersonalofrisk,control,forbehavioralacross 14Fig. 1.pregnancystatus—BehavioralRiskFactorSurveillanceSystem,UnitedStates,y1991–2005§.*Defined as five or more drinks on at least one occasion.yBRFSS data were not available for 1994,1996, 1998, and 2000. Data also were not available from Kansas, Nevada, and Wyoming for 1991;fromArkansasandWyoming for 1992;fromRhodeIslandfor1993and1994;fromtheDistrict of Co-lumbia for 1995; and from Hawaii for 2004.§Beginning in 2006, the definition of binge drinking bywomen changed to four drinks on at least one occasion. Because of this change, data collected after2005arenotincluded.Percentageofwomenaged18–44yearswhoreportedanyalcoholuseorbingedrinking,*by194Dev Disabil Res Rev?Prevention of FASDS?Floyd Et Al.

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groups overall, others found differencesin outcomes for males versus femaleswith female groups more likely to showchange in both intervention and controlgroups yielding no between group dif-ferences. Differing effects by sex werenot reported uniformly in the studiesreviewed that may have been related tosmall numbers of women represented inthe selected studies. Authors of thereview acknowledged some expectedmethodologicalproblemssample size, sample selection, additionaltreatment (i.e.,additionalsought in the months following briefintervention), andassessment (i.e., did the drinking assess-ment alone alter behavior?). However,the weight of the findings led theauthors to conclude that brief interven-tions are far better than no interven-tions; compare favorably in outcomes tomore extensive interventions; appear toenhance the effects of subsequent treat-ment; and provide encouraging evi-dence for changing harmful drinkingpatterns among adults in health careand treatment settings.In 1996, the World Health Orga-nization(WHO)Study Group [1996] reported the find-ings of a noteworthy study focused onthe effects of simple advice and briefcounseling on hazardous drinking inadults representing a variety of culturalgroups in eight developing and devel-oped countries. The study was con-ducted in diverse health care settingsincluding primary care. Of the 1,559subjects enrolled, ?75% were male.Subjects were randomized into threegroups: a control group, a simple advicegroup, and a group receiving a briefintervention. Significant results werefound in men receiving the interven-tions (advice or brief intervention),with a reported 17% lower average dailydrinking amount as compared to menin the control group. Among women inthe study, significant reductions in alco-hol use occurred in both interventionand control groups with no significantbetween group differences.A later report reviewed random-ized trials specifically focusing on the ef-ficacy of brief interventions for womenin need of treatment for problem drink-ing [Chang, 2002]. The study popula-tions included groups composed only ofwomen or mixed groups that includedboth men and women with substantialnumbers of women represented. Onestudy found a brief intervention deliv-ered by general practitioners to be effec-tive in reducing excessive drinking inincludingtreatmentreactivity to theBriefInterventionboth men and women who received theintervention as compared to controls[Wallace et al., 1988]. In four reviewedstudies, women performed significantlybetter in lowering their alcohol con-sumption than men when compared tocontrols [Sanchez-Craig et al., 1989,1991; Fleming et al., 1997; Manwellet al., 2000]. Among the four remainingstudies that just included women, no sig-nificant between group differences werefound when intervention and controlgroupswere comparedAnderson, 1990; WHO Brief Interven-tion Study Group, 1996; Chang et al.,1999; Aalto et al., 2000]. The authorsnoted that the benefits for womenreceiving brief intervention for problemdrinking were not consistent across thestudies reviewed. Other reviews withmeta-analyses have found brief interven-tions effective across gender for heavydrinking and hazardous drinking [Wilket al., 1997; Ballesteros et al., 2004], andextended brief interventions effective inwomen but not men [Poikolanen, 1999].Taken together, these meta-analy-ses have yielded somewhat contradictoryconclusions in part due to the fact thatthe various studies reviewed variedwidely regarding inclusion criteria suchas alcohol use severity level, age and sexof subjects, clinical setting used forrecruitment, and differences in the com-ponents of the brief interventions. How-ever, in spite of a number of differingfindings from studies using differentmethodologies, some general conclu-sions can be derived from this research. Itappears that both men and women bene-fit from brief interventions; women ben-efited more than men in some trials thatmay reflect lower levels of alcohol useand higher motivation for behavioralchange in women, and, in the context ofa therapeutic situation, women maychange their behavior regarding alcoholuse simply in response to questions abouttheir drinking. This latter conclusion isbased on the finding that, in some stud-ies, women in the control groups whowere just asked about their drinking lev-els performed similarly to the women inthe brief intervention groups.[ScottandINTERVENTIONSFOR PREVENTINGALCOHOL-EXPOSEDPREGNANCIES (AEP) INWOMEN OF CHILDBEARINGAGEIn2004,Services Task Force (USPSTF) reportprovided a summary of the evidenceupon which the USPSTF would baseaU.S. Preventivetheir recommendations for identifyingand intervening with risky or harmfuldrinkers [Whitlock et al., 2004]. Theevidence summary was derived from areview of 12 randomized, controlledtrials of brief interventions in adults. Allbut one was conducted in primary carepractices. Most had more than 300 par-ticipants (one-thirdwomen) and a 12-month follow-upperiod. The review concluded thatbehavioral counselingwere effective for risky or harmfuldrinking among adult primary carepatients. The official recommendationstatement released by the USPSTF rec-ommended screening and behavioralcounseling interventions to reduce alco-hol misuse by adults, including pregnantwomen, in primary care settings [U.S.Preventive Services Task Force, 2004].The statement acknowledged that therewas limited evidence to support theeffectiveness of counseling to reducealcohol use during pregnancy, but statedthat studies did show that behavioralcounseling interventions were effectivein reducing alcohol use among womenof childbearing age in general. Forexample, one study from the USPSTFreview found that two 15-min physi-cian-delivered brief intervention sessionsresulted in a 20–25% reduction indrinks per week and binge drinkingepisodesamongwomen 18–40 years who screened posi-tive for problem drinking at studyenrollment [Manwell et al., 2000].Since the USPSTF review wasconducted, two well-controlled studieshave been reported on the use of briefinterventions in pregnant women ofchildbearing age. A 2005 randomizedstudy of pregnant women found that asingle brief intervention counseling ses-sion that included partners was effica-cious in reducing alcohol use amongthe heaviest drinkers in the treatmentgroup [Chang et al., 2005]. A laterrandomized trial of a brief interventiontargetedpregnantWomen, Infants, and Children Centersand followed them through the thirdtrimester[O’Connor2007]. Reported results showed thatwomen in the brief intervention groupwere five times less likely to continuedrinking during pregnancy than womenin the assessment only group. In addi-tion, newborns of mothers who wereheavier drinkers in the interventiongroup had better growth (higher birthweights and longer birth lengths) andlower fetal mortality rates than those inthe assessment only group. This studyofwhichwereinterventionschildbearing-agedwomenattendingandWhaley,Dev Disabil Res Rev?Prevention of FASDS?Floyd Et Al.195

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was one of the few studies that havebeen conducted in a community, ratherthan a primary care setting using non-medical professionals for the administra-tion of the brief intervention.Given the high rates of hazardoususe of alcohol among childbearing-agedwomen in the United States (Fig. 1),the ideal time to reach them with infor-mation, advice, and assistance is prior toconception. A randomized trial of abrief motivational intervention to dothis was reported in 2007 [Floyd et al.,2007]. This study, conducted in diverse,community-basedfour counseling sessions and a contra-ception consultation and services visitto women at high risk for an AEP.Women in the control group receivedinformation and resources for addressingproblem drinking and for family plan-ning services. At 3, 6, and 9 months,the odds of reducing the risk for anAEP were twofold higher in the inter-vention group over the information(control) group.The evidence base for use of briefinterventions in preventing AEPs inwomen of childbearing age led theClinical Working Group of the SelectPanel on Preconception Care, Centerssettings, providedfor Disease Control and Prevention(CDC), to put forth the following rec-ommendation in 2008 for women inthe preconception period:All childbearing-aged women should bescreened for alcohol use and brief interventionsshould be provided in primary care settings includ-ing advice regarding the potential for adverse healthoutcomes. Brief interventions should include accu-rate information about the consequences of alcoholconsumption including the effects of drinking dur-ing pregnancy, that effects begin early during thefirst trimester and that no safe level of consumptionhas been established. Contraception consultationand services should be offered and pregnancydelayed until it can be an alcohol-free pregnancy.[Floyd et al., 2008, p. S335].MOVING SCIENCE TOPRACTICE THROUGH POLICYDEVELOPMENT ANDIMPLEMENTATIONIn 1996, the Institute of Medicine(IOM) stressed the importance of inte-gration and coordination at the federallevel in order to prevent and treat thefull spectrum of individuals with alco-hol-related problems [Stratton et al.,1996]. Since that time, there have beenseveral national efforts that have facili-tatedadvances inNational Institute on Alcohol Abusethisarea. Theand Alcoholism created the InteragencyCoordinating Committee on FAS in1996 comprised of various federal agen-cies conducting research and programactivities on prenatal alcohol exposure.The committee helps to foster exchangeof information and ideas across federalagencies and encourages collaborativeprojects. The National Task Force onFetal Alcohol Syndrome was mandatedby the U.S. Congress in 1998 to adviseand foster coordination among agencies,academic bodies, clinicians, and com-munity groups regarding research, pro-grams on prenatal alcohol exposure,surveillance, and to address the needs ofindividuals with FASDs and their fami-lies. In 2002, the Substance Abuse andMental Health Services Administration’sFASD Center for Excellence was cre-ated to support the development ofFASD prevention, treatment, and caresystems at the state and communitylevel. Other national groups, includingthe National Organization on FAS andits state affiliates, the Arc, the March ofDimes, the Center for Science in thePublic Interest, the American Academyof Pediatrics, and the American CollegeofObstetricians andalong with other state and local organi-zations, have also worked together andwith federal agencies to raise awarenessand visibility about FASDs as an impor-tant public health problem.Recognizing the need to identifyeffective interventions to reduce AEPs,the National Task Force on Fetal Alco-hol Syndrome and Fetal Alcohol Effect,congressionally mandated and convenedby the CDC, established a preventionworking group in 2004 to develop areport on evidence-based strategies forFASD prevention. Several task forcemeetings focused on prevention, high-lighting both population-based and clin-ical intervention strategies to reducealcohol use and AEPs. A review of theliterature to identify effective commu-nity-level FASD prevention interven-tions and policies, evidence from exist-ing systematic reviews on brief alcoholinterventions, and deliberations amongtask force members and the report writ-ing group helped lay the groundworkfor the information and recommenda-tions (Fig. 2) put forth in the recentTask Force Report, Reducing Alcohol-Exposed Pregnancies: A Report of theNational Task Force on Fetal AlcoholSyndrome and Fetal Alcohol Effect [Barryet al., 2009]. The report categorizedinterventions usingframeworkdeveloped[Stratton et al., 1996]. This frameworkGynecologists,thebypreventiontheIOMFig. 2.alcohol effect.Recommendations from the National Task Force on fetal alcohol syndrome and fetal196Dev Disabil Res Rev?Prevention of FASDS?Floyd Et Al.

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consists of universal, selective, and indi-cated strategies for prevention. Below isa summary of the findings and recom-mendations from this report.Universal Prevention StrategiesUniversal prevention interventionsattempt to promote the health of thegeneral public or a particular group,regardless of risk. Although there hasbeen some important work in this area,including media campaigns [Kaskutasand Graves, 1994; Glik et al., 2001],point-of-purchase signage [Prugh, 1986],and alcoholic beverage labeling [Hankinet al., 1993, 1996], the outcomes of theseefforts do not demonstrate reductions inalcohol use or FASDs. The Task Forcerecognized the important role thesekinds of strategies play in educating thegeneral public and raising awarenessabout FASDs as part of a comprehensiveFASD prevention approach; however,they recommended that more research isneeded to determine the effects of uni-versal approaches on alcohol use patternsand reproductive health outcomes ofwomen of childbearing age. The TaskForce also supported the implementationof effective broad-based alcohol preven-tion strategies, such as increasing alcoholtaxes and reducing access to alcohol, toreduce alcohol-related harm in the gen-eral population [Babor et al., 2003;Guide to Community Preventive Ser-vices, 2009].Selective and Indicated PreventionStrategiesSelective andstrategies are targeted and intensive fall-ing along a continuum of care depend-ing on the severity of the alcohol-related problem. As the Task Forcereviewed the evidence, the science todate pointed to brief alcohol interven-tion as an effective approach to reduc-ing alcohol use and AEPs. As previouslyoutlined, research indicates that alcoholscreening and brief interventions havebeen found to be effective in multiplesettings, including primary care [Bienet al., 1993; Wilk et al., 1997; Poikola-nen, 1999; Ballesteros et al., 2004;Whitlock et al., 2004], emergency room[D’Onofrio and Degutis, 2002], com-munity [O’Connor and Whaley, 2007],andcollegesettingsCronce, 2002]. The Task Force recom-mended promoting the use of evidence-based strategies in these types of settingsfor women of childbearing age at riskfor an AEP.Two task force recommendationsfocused specifically on the implementa-indicated prevention[Larimer andtion and improvement of screening andbrief intervention efforts for women ofchildbearing age. Effective interventionsexist for both pregnant [Chang et al.,2005; O’Connor and Whaley, 2007]and preconceptional women [Ingersollet al., 2005; Floyd et al., 2007]. Thus,the Task Force recognized the impor-tance of establishing formal alcoholscreening and brief intervention pro-grams that are culturally and linguisti-cally appropriate for women of child-bearing age. Related to this, the TaskForce also recommended the expansionof education and training of health andsocial service professionals in the areasofscreening andwoman at risk for an AEP.interveningwithThe greatestopportunities for healthypregnancy outcomes,however, lie in preventionstrategies implementedprior to conception.Effective indicated approaches toFASD prevention among the highestrisk women, including mothers whohave previously given birth to a childwith an FASD, could have a significanteffect on the problem of prenatal alco-holexposure.However,women at highest risk for an AEP ischallenging and their treatment is com-plex. Substance abuse treatment pro-grams designed for women that includesupport services such as child care, pre-natal care, and mental health treatmentcanaffecttreatmentImprovements can include changes insubstance use, mental health symptoms,perinatal or birth outcomes, employ-ment, self-reported health status, andHIV risk reduction [Ashley et al., 2003;Brady and Ashley, 2005]. There has alsobeen success with intensive case man-agement approaches for women at high-est risk for having a child with a FASDand women who themselves have aFASD [Grantetalthough more research in this area iswarranted. The Task Force recognizedthis and also stressed the importance ofassuring access to substance abuse treat-ment services and the availability ofappropriate substance abuse treatmentoptions for women of childbearing age.Additional research is also needed toreachingoutcomes.al.,1996, 2004],explore interventions focused on thepotentialintergenerationalprenatal alcohol use on children ofwomen who have FASDs.effectsofCONCLUSIONSStudies cited in this review havedocumented the efficacy of screeningand brief interventions for women ofchildbearing agedrinking and AEPs, and in improvingfetal growth and decreasing fetal mortal-ity among risky drinkers. Brief inter-ventions should include clinical adviceand counseling regarding the risk posedby prenatal alcohol exposure, discussionof the woman’s readiness to change, andassistance in helping the woman to de-velop strategies and goals for reducinghazardous use of alcohol during preg-nancy. In addition to providing briefinterventions, follow-up should be con-ducted for every high-risk woman, andany woman who is unable to achieveherdrinkinggoalsstepped up care including referral toformal treatment programs or commu-nity group interventions that providesupport to women seeking to reducehazardous alcohol use.Thegreatesthealthy pregnancy outcomes, however,lie in prevention strategies implementedprior to conception. Importantly, healthcare providers should understand thatearly prenatal care is often too late formany women and babies particularlygiven that approximately half of thepregnanciesinthisunplanned [Finer and Henshaw, 2006].Evidence-basedinterventionsmended for implementationpregnancy would be most beneficial ifimplemented before conception. Briefbehavioral interventions to reduce alco-hol use prior to conception and coun-seling regarding effective contraceptiveoptions when not planning a pregnancyhave been proven to be effective meth-ods for preventing an AEP.The National Task Force on FetalAlcohol Syndrome and Fetal AlcoholEffect has proposed many strategies forthe future. These strategies include test-ing the effectiveness of universal preven-tion methods and promoting the imple-mentation of empirically validated meth-ods on the general population, includingwomen of childbearing age. Regardingselective and indicated prevention, it is rec-ommended that funded studies includeanalyses of individual differences, pro-mote the use of culturally sensitive evi-dence-based intervention methods inmultiple settings in which women areinreducingriskyshould receiveopportunities forcountry arerecom-duringDev Disabil Res Rev?Prevention of FASDS?Floyd Et Al.197